Porth (2020) 5th nur 317 Flashcards
Chapter 16
Which symptoms would support the diagnosis of a stroke involving the posterior cerebral artery? Select all that apply.
Repeating of verbal responses
Loss of central vision
Contralateral hemiplegia
Aphasia
Denial of paralyzed side
Repeating of verbal responses,
Loss of central vision
Rationale:Posterior cerebral artery stroke would produce visual defects and the repeat of verbal and motor responses. The other options are seen in middle cerebral artery strokes.
The health care provider is concerned that a client may be at risk for problems with cerebral blood flow. The most important data to assess would be:
Decreased level of oxygen
Decreased level of PCO2
Decreased hydrogen ions
Decreased level of carbon dioxide
Decreased level of oxygen
Rationale:Regulation of blood flow to the brain is controlled largely by autoregulatory or local mechanisms that respond to the metabolic needs of the brain. Metabolic factors affecting cerebral blood flow include an increase in carbon dioxide and hydrogen ion concentrations; cerebral blood flow is affected by decreased O2 levels and increased hydrogen ions, carbon dioxide, and PCO2 levels.
The emergency room doctor suspects a client may have bacterial meningitis. The most important diagnostic test to perform would be:
CT of the head
Lumbar puncture
Blood cultures
Sputum culture
Lumbar puncture
Rationale:The diagnosis of bacterial meningitis is confirmed with abnormal CSF findings. Lumbar puncture findings, which are necessary for accurate diagnosis, include a cloudy and purulent CSF under increased pressure. The other options do not confirm the diagnosis.
Which medication would be recommended for myoclonic seizures?
Gabapentin
Valproic acid
Lamotrigine
Carbamazepine
Valproic acid
Rationale:Valproic acid has proven to be effective with myoclonic seizures. The other medications are used primarily with partial seizures or tonic-clonic seizures.
A nurse in the emergency room is assessing a client who appears very drowsy but is able to follow simple commands and respond to painful stimuli appropriately. Which documentation is most accurate regarding this client’s level of consciousness?
Obtundation
Stupor
Confusion
Lethargy
Obtundation
Rationale:Characteristics of obtundation include responding verbally with a word, arousable with stimulation, responds appropriately to painful stimuli, follows simple commands, and appears very drowsy.
Which individual has the highest chance of having a primary central nervous system lymphoma?
A 24-year-old man with acquired immunodeficiency syndrome (AIDS) and behavioral and cognitive changes
A 60-year-old woman who is soon to begin radiation therapy for the treatment of breast cancer
An 88-year-old man who has begun displaying signs and symptoms of increased ICP
A 68-year-old man who is a smoker and has a family history of cancer
A 24-year-old man with acquired immunodeficiency syndrome (AIDS) and behavioral and cognitive changes
Rationale:Primary CNS lymphomas are especially common in immunocompromised persons, including those with acquired immunodeficiency syndrome (AIDS) and immunosuppression after transplantation. Behavior and cognitive changes, which are the most common presenting symptoms, occur in about 65% of clients.
A client is brought to the emergency department and is diagnosed with an ischemic stroke confirmed by CT scan. The most important treatment for this client would be to:
administer analgesics for the relief of pain.
monitor vital signs closely for improvement.
administer IV tissue plasminogen activator (tPA).
prepare the client for emergency surgery.
administer IV tissue plasminogen activator (tPA).
Rationale:tPA administration is the treatment of choice for an ischemic stroke after confirmation that it is not a hemorrhagic stroke. Monitor vital signs and provide pain relief to prevent complications.
A client has started having uncontrolled seizures that are not responding to usual medications. Nurses working with the client must pay special attention to which priority aspects of this client’s care? Assessment of:
Urine output and continence
ECG for arrhythmias
Ability to grasp hands and squeeze on command
Respiratory status and oxygen saturation
Respiratory status and oxygen saturation
Rationale:Tonic–clonic status epilepticus is a medical emergency and, if not promptly treated, may lead to respiratory failure and death. Treatment consists of appropriate life support measures. Airway/breathing is always the priority in this emergency situation.
Generalized convulsive status epilepticus is a medical emergency caused by a tonic–clonic seizure that does not spontaneously end, or recurs in succession without recovery. What is the first-line drug of choice to treat status epilepticus?
Intravenous lorazepam
Intramuscular cyproheptadine
Intramuscular diazepam
Intravenous cyclobenzaprine
Intravenous lorazepam
Rationale:Treatment consists of appropriate life support measures. Medications are given to control seizure activity. Intravenously administered diazepam or lorazepam is considered first-line therapy for the condition. Lorazepam is not given intramuscularly in status epilepticus. Cyclobenzaprine and cyproheptadine are not used to treat status epilepticus.
A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing:
Thrombotic stroke
Lacunar infarct
Cardiogenic embolic stroke
Transient ischemic attack (TIA)
Transient ischemic attack (TIA)
Rationale:Transient ischemic attacks are brief episodes of neurologic function resulting in focal cerebral ischemia not associated with infarction that usually resolve in 24 hours. The causes of transient ischemic attack are the same as they are for stroke. Embolic stroke usually has a sudden onset with immediate maximum deficit. Lacunar infarcts produce classic recognizable “lacunar syndromes” such as pure motor hemiplegia, pure sensory hemiplegia, and dysarthria with clumsy hand syndrome.
According to the Glasgow Coma Scale, opening one’s eyes to only painful stimuli would receive which score?
2
3
1
4
2
Rationale:Only opening eyes to painful stimulation is scored as a 2. Spontaneously opening eyes is scored as a 4; opening eyes to speech is scored as a 3; no opening is scored as a 1.
The emergency department nurse is caring for a client who fell and has a head injury. Which assessment would be noted during the early stage of increased intracranial pressure?
Stable vital signs
Nonreactive pupils
Vomiting
Hemiplegia
Stable vital signs
Rationale:The vital signs remain unchanged in the early stage of increased intracranial pressure. The remaining options are characteristic of late signs.
A client who is diagnosed with seizures describes feeling a strange sensation before losing consciousness. The family members report that the client has been smacking his lips prior to having a seizure. Which type of seizure disorder presents with these symptoms?
Generalized seizures
Simple partial seizure or prodrome
Atonic seizure
Complex partial or focal seizure with impairment of consciousness
Complex partial or focal seizure with impairment of consciousness
Rationale:Complex partial seizures, or focal seizures with impairment of consciousness, are often accompanied by automatisms, which are repetitive, nonpurposeful activities such as lip smacking, grimacing, patting, or rubbing clothing. They are sometime called psychomotor seizures. Simple partial seizures, or prodromes, would not have a loss of consciousness. Atonic seizures, a category of generalized seizures, indicate involvement of both brain hemispheres at the onset.
The CT scan report identified that a client with a skull fracture has developed a hematoma that resulted from a torn artery. The report would be interpreted as:
Intracranial hematoma
Epidural hematoma
Subdural hematoma
Chronic subdural hematoma
Epidural hematoma
Rationale:An epidural hematoma is one that develops between the inner side of the skull and the dura, usually resulting from a tear in an artery, most often the middle meningeal, usually in association with a head injury in which the skull is fractured. A subdural hematoma results from a torn vein; chronic subdural hematoma is common in older persons. Brain atrophy causes the brain to shrink away from the dura and to stretch fragile bridging veins. An intracranial hematoma occurs when a blood vessel ruptures within the brain or between the skull and the brain.
A child has developed a benign brain tumor in the cerebellum and the floor of the third ventricle. The proper documentation for this type of tumor includes which terminology?
Pilocytic astrocytomas
Fibrillary astrocytomas
Oligodendrogliomas
Ependymomas
Pilocytic astrocytomas
Rationale:Pilocytic astrocytomas are commonly found in children and young adults, typically located in the cerebellum or in the floor and walls of the third ventricle, in the optic chiasm and nerves, and occasionally in the cerebral hemispheres. These tumors are benign and grow slowly. The other tumors do not occur in the walls of the cerebellum.
A client’s recent computed tomography (CT) scan has revealed the presence of hydrocephalus. Which treatment measure is most likely to resolve this health problem?
Lumbar puncture
Aggressive diuresis
Administration of hypertonic intravenous solution
Placement of a shunt
Placement of a shunt
Rationale:Hydrocephalus represents a progressive enlargement of the ventricular system due to an abnormal increase in cerebrospinal fluid (CSF) volume. This increase in CSF volume can be resolved by the placement of a shunt to drain the offending fluid volume. Diuresis, hypertonic solution administration, and lumbar puncture are not usual treatment modalities.
The nurse is explaining to a client’s family how vasogenic brain edema occurs. The most appropriate information for the nurse to provide would be:
Normal physiologic circumstances result in decreased adsorption of CSF.
The blood–brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.
There is an increase in the production of cerebrospinal fluid volume.
There is a decrease in the amount of fluid volume in the brain.
The blood–brain barrier is disrupted, allowing fluid to escape into the extracellular fluid.
Rationale:Vasogenic brain edema occurs with conditions that impair the function of the blood–brain barrier and allow the transfer of water and protein from the vascular space into the interstitial space. Increased production of CSF and decreased absorption result in hydrocephalus. It occurs in conditions such as hemorrhage, brain injury, and infectious processes.
The nurse would consider which factors when providing education regarding modifiable risk factors for stroke? Select all that apply.
Avoiding excessive alcohol use
Controlling blood pressure
Selecting low fat foods
Monitoring diabetes mellitus
The early syptoms of an impending stroke
Avoiding excessive alcohol use, Controlling blood pressure, Selecting low fat foods, Monitoring diabetes mellitus
Rationale:Hypertension, hypercholesteremia, diabetes, and heavy alcohol use are all modifiable risk factors for stroke. Identifying the signs of impending stroke assures early intervention but does not affect the risk of developing the condition.
The family of a male client documented to be in a vegetative state excitedly reports to the nurse that the client has just opened his eyes for the first time. The best response by the nurse is:
“Clients in a vegetative state often open and close their eyes.”
“I will come and assess the client.”
“That is a just a reflexive action.”
“That is a miracle.”
“I will come and assess the client.”
Rationale:The nurse should assess the client for concurrent awareness as this is the first time that the spontaneous eye opening has occurred. The nurse should be aware that clients in a persistent vegetative state often have spontaneous eye opening without concurrent awareness. This is often confusing for hopeful families.
